Healthcare Provider Details

I. General information

NPI: 1821504788
Provider Name (Legal Business Name): MARYVILLE ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 N CLAREMONT AVE
CHICAGO IL
60622-1710
US

IV. Provider business mailing address

1455 E GOLF RD STE 210
DES PLAINES IL
60016-1254
US

V. Phone/Fax

Practice location:
  • Phone: 312-491-3509
  • Fax: 312-391-3531
Mailing address:
  • Phone: 847-390-3004
  • Fax: 847-390-3016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NANCY Z WOULFE
Title or Position: DIRECTOR OF BUSINESS DEVELOPMENT
Credential:
Phone: 847-294-1910